The Premium IOL Patient Journey Important Keys to Success

The Premium IOL Patient JourneyImportant Keys to Success

Vance Thompson, MDFounder, Vance Thompson Vision

Professor of Ophthalmology, University of South Dakota, Sanford School of MedicineSioux Falls, South Dakota, USA

65th Rochester Ophthalmology Conference

Financial DisclosuresAlcon Laboratories: Consultant/Research

Allotex: Consultant/Advisor

Allergan: Consultant/Research

AcuFocus: Consultant/Research

Avsi: Consultant/Research

Bausch Lomb: Consultant/Advisor/Research

BVI Consultant/Advisor/Research

Carl Zeiss Meditec: Consultant/Research

Equinox: Consultant/Investor

Euclid Systems: Consultant/Advisor

Novartis Pharmaceuticals: Research

Vivor AG: Advisor/Research

Keratonics/Advisor/Consultant

Johnson and Johnson: Consultant/Research

Oculeve: Consultant/Advisor, Equity Owner

OPHTEC: Consultant/Advisor/Research

Precision Lens: Consultant/Advisor

Treehouse Eyes: Consultant/Investor

Tarsus Rx: Consultant

EyeBrain Medical Inc: Equity Owner

Imprimis: Consultant/Advisor

Mynosys: Consultant/Advisor/Research

EyeGate Pharmaeuticals: Consultant/Research

RxSight: Consultant/Research

TearClear: Consultant/Advisor, Equity Owner

Over 80 FDA Monitored Trials

• PRK

• PTK

• LASIK

• Phakic IOL’s

• Corneal Inlays

• Collagen Crosslinking

• SMILE

• Light Adjustable Lens

• Multifocal IOL’s

• PRK• PTK• LASIK• Phakic IOL’s• Corneal Inlays• Collagen Crosslinking• SMILE• Light Adjustable Lens

Insurance Patient Pay

The ComprehensiveRefractive Cataract Surgeon

2020

Traditionaland

Refractive CataractSurgery

Our #1 Goal in Cataract Surgery• Make the patient happy

What type of cataract surgery

would this patient want…

What type of cataract surgery

would this patient want…if they

had my knowledge and

experience?

Important Cause of Un-Happy Patients

• Same approach for every patient

• Ignores: Different patients have different goals

Modern Day Cataract Surgery

Patient Centered ApproachModern Day Cataract Surgery

Options

• Lost Lens Function Replacement


Options


• How to Handle Residual Refractive Error


Options



PostopUCVA: 20/20-1 Mrx: +.25 - .75 X 180

Plano• Traditional-Glasses

• Advanced-PRK, LASIK, or AK (Corneal Adjustable)

-Light Adjustable Lens (Optic Adjustable)

Modern Day Cataract Surgery

Glasses vs No Glasses

• How do you want to visually function

comfortably

the majority of your day?


Options



PostopUCVA: 20/20-1 Mrx: +.25 - .75 X 180

Traditional Cataract Surgery


Options



PostopUCVA: 20/20-1 Mrx: +.25 - .75 X 180

Traditional Cataract SurgeryNight time glare

Decreased image quality in low light


Options



PostopUCVA: 20/20-1 Mrx: +.25 - .75 X 180

Traditional Cataract SurgeryNight time glare

Decreased image quality in low lightGlasses


Options



PostopUCVA: 20/20-1 Mrx: +.25 - .75 X 180

Advanced Cataract Surgery


Options



PostopUCVA: 20/20-1 Mrx: +.25 - .75 X 180

Advanced Cataract SurgeryNight time glare

Decreased image quality in low light


Options



PostopUCVA: 20/20-1 Mrx: +.25 - .75 X 180

Advanced Cataract SurgeryNight time glare

Decreased image quality in low lightLaser Fine Tune


Options



99.2%*

• The % of PanOptix patients in the FDA monitored trial

on our county’s first Trifocal who said “I would do the

same implant again”

*

89.0%

• The % of Monofocal Control patients in the FDA

monitored trial on our county’s first Trifocal who said “I

would do the same implant again”

99.2% vs 89.0%Would I do the same implant again?

Tri-focal Mono-focal


Options



Advanced Cataract Surgery:• Trifocal• Light Adjustable Lens

Trifocal IOL

Presbyopia Patients Demand Solutions to

Meet Their Full Visual Range Lifestyle

• Visual quality in the intermediate range is critical with increasing digital

device usage

• Bifocal technology provides only distance, and near or intermediate vision

ranges (depending on the Add)

• Trifocal technology allows for 3 distinct foci that can provide the full range of

vision from near through intermediate to distance

Severe Visual Disturbances on QUVIDSafety-analysis set; first eye, at 6 months post-op

Percentage calculated as (n/N)*100; Severe visual disturbance defined as patient responding “Severe” on QUVID. Error bars represent 95% CI

®

The observed rates of starbursts and halos were higher in the Trifocal IOL group than the Monofocal IOL group

Total patients N

Trifocal

Patient Satisfaction All-implanted analysis set; at 6 months post-op

* Response to question: in the past 7 days, how satisfied were you with your vision?

Response Trifocal n (%)

Monofocaln (%)

Total 127 111

Would you have the same lens

implanted again?

No 1 (0.8) 14 (12.6)

Yes 126 (99.2) 97 (87.4)

Total 127 110

Would you recommend the lenses you had implanted to your family or

friends?

No 2 (1.6) 5 (4.5)

Yes 125 (98.4) 105 (95.5)

1.6 1.6 1.6

21.3

74

0 2.7 6.4

30.9

60

0

20

40

60

80

100

Very Dissatisfied Dissatisfied Neither Satisfiednor Dissatisfied

Satisfied Very Satisfied

Re

spo

nse

(%

)

Satisfaction with Your Vision*

PanOptix (n=127) Monofocal (n=110)Trifocal (n=127)

Post-Cataract Surgery

Refractive Error

Cataract Surgery Outcomes

* Norrby, S. Sources of error in intraocular lens power calculation. JCRS 2008: 368-76

Error Source Contribution*

Post-op IOL Position 35%

Post-Op Corneal Power 15%

Axial Length 17%

Challenge to consistently achieve great results

• 2016 toric meta-analysis1: ~65% of eyes achieve 20/25 or better

• Limited by ability to predict the post-operative eye

1. Line Kessel, MD, PhD, Et Al. Toric Intraocular Lenses in the Correction of Astigmatism During Cataract Surgery – A Systematic Review and Meta-Analysis Ophthalmology. 2016 Feb;123(2):275-86

https://www.ncbi.nlm.nih.gov/pubmed/26601819

At the plant

All Implants are Adjustable

The power of adjustability

inside the eye

Light Adjustable Lenses

UV photosensitive IOL Post-op adjustment range (any combination):

-2 to +2 diopters (sphere)0.75 to 2 diopters (cylinder)

Light is adjusted by the surgeon

to the light adjustable lens

• LAL eyes achieved UCVA of 20/20 or better at 6 months postoperatively at approximately 2x the rate of patients receiving a monofocal lens

• 91.8% of LAL eyes achieved result within 0.50 D of target MRSE (similar to LASIK results)

• Superior Quality of Vision at all measures compared to control lens:

• Including BCVA, Vision Rating, Driving Difficulty, Dim Light Conditions, Glare, Halos, and all measures of Contrast Sensitivity

LAL

LAL

LAL (n=391)

US FDA Study Results

79,206

48,052

12,807

2,510

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

< .5D 0.5D - 1.0D 1.0D -2.0D > 2.0D

European Cataract Outcomes Study

6X Reduction With LAL!• In LAL PMA only 8.2% had ≥0.5

diopter error

• In the largest-ever study of 143,000 patients in Europe,

nearly 45% were left with refractive error ≥0.5 diopters

US FDA Study Results

Light Adjustable Lens Process

h h

Matrix

Photosensitivesilicone macromer

Polymerizedmacromer

Unpolymerized macromerdiffuses to central region & causes swelling

Increasedpower

(a) (b) (c)

hh hh

Matrix


Matrix


Polymerizedmacromer


Increasedpower

Increasedpower

(a) (b) (c)

h h

Matrix


Polymerizedmacromer


Increasedpower

(a) (b) (c)

hh hh

Matrix


Matrix


Polymerizedmacromer


Increasedpower

Increasedpower

(a) (b) (c)

h h

Matrix


Polymerizedmacromer


Increasedpower

(a) (b) (c)

hh hh

Matrix


Matrix


Polymerizedmacromer


Increasedpower

Increasedpower

(a) (b) (c)

h h

Matrix


Polymerizedmacromer


Increasedpower

(a) (b) (c)

hh hh

Matrix


Matrix


Polymerizedmacromer


Increasedpower

Increasedpower

(a) (b) (c)

Standard cataract implant procedure

Residual refractive error is determined using standard phoropter

Refractive error is entered into Light Delivery Device

17-21 days

Desired light profile delivered by machine

PoylmerizationModified ShapeLockin Light exposure

• First Ever “Patient Trial’ of final

outcome

• Patient previews different

refractions

• Refraction optimized after healing is

complete and ocular media clear

• Increase Optometric (OD)

engagement

Interactive Post-Op Process

Adjustable MonovisionSurgery

• Bilateral LAL implantation

Pre-Adjustment

• Ocular dominance and anisometropia tolerance re-

evaluated after cataract removal and before LDD

adjustments

Adjustments

• Binocular vision can be optimized by adjusting

distance and near sphere targets

• Potential to reverse if not satisfied

1. 2015/2016 ASCRS Survey 2. Average over all IOLs 3. Doane Data FDA Study

Improved Toric Accuracy

• LAL will provide superior reduction in

astigmatism

– No corneal marking

– No unpredictable toric rotation

– Treats corneal and surgically induced

astigmatism postoperatively

– Spherical correction for free!

1. 2015/2016 ASCRS Survey 2. Average over all IOLs 3. Doane Data FDA Study

Post Corneal Refractive Eyes

FDA IDE study currently fully enrolled to evaluate the LAL these challenging

eyes

• Post-LASIK population is increasingly entering the

age range for cataract surgery

• Refractive results in this group are inferior to those

in non-LASIK eyes because of:

– Inaccuracy in determining the total corneal

refractive power due to reshaped cornea

• LAL should dramatically improve results in this

group due to post-operative adjustability

62 y.o. female

1/11/19 Refractive Consult

• 2006 Hyperopic LASIK +3.00 +4.00

• 2008 Lift flap and laser +1.00-.50 X 166 +1.00

• 2010 AK OD Lift and laser OS +.50-1.00 X 166 +1.00

•

Exam 1/11/19UCVA: OD: 20/30-2

OS: 20/30-2MRx: +.75-50x 150 20/25-2 +1.00 20/25-2BAT: 20/60

20/60

OD OS

62 y.o. female


Exam 1/11/19UCVA: OD: 20/30-2 OS: 20/30-2MRx: +.75-50x 150 20/25-2 +1.00 20/25-2BAT: 20/60 20/60Dx: NS cataracts OUWants multifocal implants

OD OS




Epithelial Thickness Map

62 y.o. female





•

Exam 1/11/19UCVA: OD: 20/30-2 OS: 20/30-2MRx: +.75-50x 150 20/25-2 +1.00 20/25-2BAT: 20/60 20/60Dx: NS cataracts OUWants multifocal implants

OD OS

Light Adjustable

Lens

Monofocal Implant

OD: planoOS: -1.00

Extended Depth of

Focus Surgery

• Bilateral LAL implantation with post-operative emmetropic

target OU

Advantages

• Full cylinder and residual cylinder correction OU enhances

UCVA and reduces dysphotopsias

• Centration on undilated pupil overcomes one of drawbacks

of traditional multifocal IOLs (susceptibility to IOL

decentration)

• Small diameter of the EDF light treatment preserves both

UCDVA and BCDVA

• No splitting of light, so minimal, to no loss of contrastCaution: EDF is Investigational in the U.S. Limited by Federal Law to investigational use.

The

Differentiator

“It’s about people”

Which face looks more attractive?

https://www.newscientist.com/article/dn12886-eye-contact-and-a-smile-will-win-you-a-mate

The Science of Nice

The Experience

The People Experience The Key to Thriving in Modern Day Practice

Team Comes First

• Patients Come Second

I Care So Much About My Co-Worker That:


• I am kind to them.

• I think of them as work family

• I care about what they care about (example: their family)

• Every day when I first see them I say hi and smile with eye contact…and mean it.

• I interview others thinking about their influence on them

• When I am deciding to close the clinic for a holiday I am thinking of their joy and not my cost.

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

• When they make an honest mistake I accept their apology and don’t lose my temper

• If I lose my temper I don’t feel right until I apologize

• When they stop by the office to introduce their loved one or child I drop everything to talk and meet them

• When I hear something nice about them I tell them.

• I encourage them when they seem down.

• If my team answers these questions for me they would say I treat these situations like I say I do.

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No


Improving the Customer Experience

• You need to know what your customer values


• You need to know what your customer expects




Motivator




Motivator

Hygiene Factor


Hygiene Factors Motivators


Hygiene Factors

• Technology

• Talent

• Experience


Hygiene FactorsMotivators

• How I made them see

• How your staff treats them

• How you treat them

• Patient call backs by surgeon

• Thank you notes

How you made them feel

• Technology

• Talent

• Experience


What Technology For My Eye?

What Vision Do You Want?

“what type of cataract surgery would this patient want if they knew what I knew?”

A Refractive Surgery Mindset

Do you need a laser to do premium

IOL’s?

What You Tell Your Patient

Pre-experience Expecations

Multiple Steps-Plus Time

1. Advanced implant

2. Laser fine tune

3. YAG Laser capsulotomy


Sometimes 20/20 is Not Enough

• Small corrections matter…show

them…they can decide

• Dry eye matters

• Surface irregularities matter

• Gas perm over-refraction

The Accuracy of Fine Tunes

UCVA Drives Satisfaction

• Schallhorn, AECOS 2016

67%58%

46% 40% 33%

29%36%

42%41%

40%

4% 6% 12% 19%27%

0%

20%

40%

60%

80%

100%

12.5 16 20 25 40

Very Satisfied Satisfied Dissatisfied or Neither

Lessons from LASIK:

20/ 20/ 20/ 20/ 20/


• Advanced implant

• Laser fine tune

• YAG Laser capsulotomy Not a lot different than traditional

42


• Advanced implant

• Laser fine tune

• YAG Laser capsulotomy Neural adaptation starts

after 20/20 achieved


1. Advanced implant

2. Laser fine tune



3 Steps +

1 Year

Neural adaptation

• Cornea

• Phakic IOL

• Crystalline Lens

Comprehensive Refractive Surgery 2020

Low Light Image Quality

Diagnosis of Early Cataract

Clarity and Accommodation

Lens Functions and “The Talk”

47 year old female…Nuclear

Cataracts• OD: -0.75-.50 X 166 20/20-3 BAT: 20/100

• OS: -1.00-.75 X75 20/25 BAT: 20/100

• Ok with bifocals… “worn them since age 40…”

47 year old female…Nuclear

Cataracts• OD: -0.75-.50 X 166 20/20-3 BAT: 20/100

• OS: -1.00-.75 X75 20/25 BAT: 20/100

• Ok with bifocals… “worn them since age 40…”

• Cataract surgery aspheric Monofocal implants OU (Tecnis ZCBOO)

• 3 months Post Op: – OD: -.75-.25X170 20/20

– OS: -.50-.50X79 20/20

“Why didn’t you talk me into that fancy implant?”

Do any of you talk about early cataracts

helping patients with reading range?

61 year old male• Truck driver

• Vision not too bad…some night time glare…examining doctor said he didn’t pass his driving test

• OD: -1.25 20/25 BAT: 20/50

• OS: -1.25 20/25-1 BAT: 20/50

• Cataract surgery aspheric Monofocal implant (TecnisZCBOO)

• Post Op: – OD: -1.25-.25X180 20/20

– OS: -1.25 20/20

Very Upset with “Loss of Near Vision”

61 year old male• Truck driver

• Vision not too bad…some night time glare…examining doctor said he didn’t pass his driving test

• OD: UCVA: Distance: 20/60 Near: J1 Mrx: -1.25 20/25 BAT: 20/50

• OS: UCVA: Distance: 20/60 Near: J1 Mrx: -1.25 20/25-1 BAT: 20/50

• Cataract surgery aspheric Monofocal implant (Tecnis ZCBOO)

• Post Op: – OD: -1.25-.25X180 20/20

– OS: -1.25 20/20

Very Upset with “Loss of Near Vision”

Near

Clarity

Enhancement Decisions

o Challenging

56 yo Caucasian Female…Consult• Cataract Consult 2018

• “Can’t get a clear image at distance or near with

glasses or contacts”

• OD: -4.25-.25x12 20/25 BAT:20/50

• OS: -4.75-.75x159 20/25-2 BAT:20/50

• She doesn’t want monovision and wants the reading

range of a multifocal but worried about night time

glare.

62

• OD Dominant

• Tear Lab:

– OD: 312

– OS: 315

• Slit Lamp Exam:

– Lower permanent plugs OU

– Pushed on lids and some MGD

– Corneas: clear, no stain

– Discussed Lipiflow

56 yo Caucasian Female…Exam

• Cataract Surg. 11/13/18 & 11/20/18 Ref goal

– OD: Symfony ZXROO. -.25

– OS: Tecnis Multifocal ZKBOO. Plano

• Three Month Postop (even though co-managed 100 miles away)

– OD: 20/25-2. J8

– OS: 20/20 J2

– OD: +.75-.75x115. 20/15

– OS: +.50-.25x90. 20/15

56 yo Caucasian Female

“Near not good enough…distance a bit fuzzy”

*

Called at one month post-op:“Thank you for calling I am blurry and not happy”Call ended great

• Cataract Surg. 11/13/18 & 11/20/18 Ref goal

– OD: Symfony ZXROO. -.25

– OS: Tecnis Multifocal ZKBOO. Plano

• Three Month Postop (even though co-managed 100 miles away)

– OD: 20/25-2. J8

– OS: 20/20 J2

– OD: +.75-.75x115. 20/15

– OS: +.50-.25x90. 20/15


Ultimately wanted both eyes enhanced eventhough we did just OD first…Because of image quality and feeling near still not that good after enhancing just OD.

Drifted away for a year

• 11/26/19

• Not happy. Can’t see numbers and can’t see computer without

+2.00 readers

• Exam:

• OD: 20/30 J12 +.25-.50x16 20/30-2

• OS: 20/25 J8 +.25 20/25-2

• Slit lamp looks quite good

• Does have upper plugs now also

• She is super frustrated.


Gas Permeable Contact Lens

Over-refractionOD: 20/20 CrispOS: 20/20 Crisp

• 11/26/19

• Not happy. Can’t see numbers and can’t see computer without

+2.00 readers

• Exam:

• OD: 20/30 J12 +.25-.50x16. 20/30-2

• OS: 20/25 J8 +.25 20/25-2

• Slit lamp looks quite good

• Does have upper plugs now also

• She is super frustrated.


PTK OU

OD: 20/20 Crisp J3OS: 20/20 Crisp J2OU:20/15 Crisp J1

Sometimes 20/20 is Not Enough

Small corrections matter…show them…they can decide

Dry eye matters

Surface irregularities matter

Uncorrected Visual Acuity

Gas permeable contact lens

over-refraction

A lot of

Information…Repeat…Keep In

Touch

Visual Lifestyle Monitor

134

Ambient light and color

GyroscopeAccelerometer MagnetometerDistance

Sensors

Button Buzzer

Interface

IndicatorLow-energyBluetooth

(Head motion) (Head positioning)

Distance and Temporal Report

135

Far

Intermediate

Near

Office equipment is shown for illustrative purpose only

Measurements can be mapped on two-dimensional distribution of viewing distances

Example shows the distribution of typical vision needs in the office

Different User ProfilesUser 1 User 2 User 3

User 4 User 5 User 6

User 7 User 8 User 9

Do you talk about Neural Adaptation

after cataract surgery?

• Quick phase seconds-minutes

• Longer phase months-year


1. Advanced implant

2. Laser fine tune



3 Steps +

1 Year

Neural adaptation

The Premium IOL Patient Journey Important Keys to Success

Vance Thompson, MDFounder, Vance Thompson Vision

Professor of Ophthalmology, University of South Dakota, Sanford School of MedicineSioux Falls, South Dakota, USA

Thank You!

65th Rochester Ophthalmology Conference

The Premium IOL Patient Journey Important Keys to Success

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Transcript of The Premium IOL Patient Journey Important Keys to Success